Acute pancreatitis is a protean disease capable of wide clinical variation, ranging from mild discomfort to apocalyptic prostration. Moreover, the inflammatory process may remain localized in the pancreas, spread to regional tissues, or even involve remote organ systems. This variability in presentation and clinical course has plagued the study and management of acute pancreatitis since its original clinical description. In the absence of accepted definitions for acute pancreatitis and its complications, it has not been possible to devise a clinical classification system useful for case management. Following 3 days of group meetings and open discussions, unanimous consensus on a series of definitions and a clinically based classification system for acute pancreatitis was achieved by a diverse group of 40 international authorities from six medical disciplines and 15 countries. The proposed classification system will be of value to practicing clinicians in the care of individual patients and to academicians seeking to compare interinstitutional data.

The principal cause of pancreas-specific morbidity after BPT is injury to the MPD. Parenchymal pancreatic injuries not involving the ductal system rarely result in pancreas-specific morbidity or death. Delay in recognizing MPD injury leads to increased mortality and morbidity rates. CT is unreliable in diagnosing MPD injury and should not be used to guide therapy. Initial selection of patients with isolated BPT for observation or surgery can be based on the determination of MPD integrity.

No abstract

No abstract

No abstract

Nutritional status was investigated in 10 patients who had previously undergone total gastrectomy without evidence of malignancy. The ability of these patients to ingest and absorb adequate amounts of nutrients was examined. Metabolic balance studies were also performed to discover how effectively these patients could accumulate and use the absorbed nutrients. In the controlled hospital situation, the amount of food ingested was greater than the amount required for maintenance of Ideal Body Weight. Although mild malabsorption of fat and nitrogen was documented, weight gain and positive nitrogen balance occurred. In direct contrast, food intake significantly decreased when the patients returned to their home environment. While severe malabsorption may contribute to malnutrition in the individual patient, the most common mechanism responsible for postoperative malnutrition was inadequate intake. In the occasional patient with severe malabsorption, the universal demonstration of jejunal anaerobic bacterial overgrowth offers important therapeutic implications. The relative importance of pancreatico-biliary insufficiency in promoting malabsorption remains to be determined. Construction of a Hunt-Lawrence jejunal pouch was not found to favorably affect caloric intake, weight gain, degree of malabsorption, or dumping symptoms. Although some degree of malnutrition does result from total gastric resection, in most cases it is mild and potentially correctable. Avoidance of indicated total gastrectomy due to fears of progressive postoperative malnutrition is unwarranted.

Twenty-eight consecutive patients with infected pancreatic necrosis were managed by extensive unroofing of the superior retroperitoneum, blunt pancreatic sequestrectomy, laparotomy pad packing of the lesser sac over a layer of Adaptic gauze, and scheduled re-explorations at intervals of 2-3 days (open drainage). Wounds were permitted to heal by secondary intention. All patients were maintained on intravenous hyperalimentation. Three of the 28 patients died (11%); none died of sepsis. Procedure-specific complications included: pancreatic fistula (10 patients), incisional hernia (8 patients), persistent functional gastric outlet obstruction (2 patients), retroperitoneal venous hemorrhage (2 patients), and intestinal fistula (1 patient). Limited initial experience with dynamic pancreatography and serial monitoring of acute phase reactants as indicators of pancreatic necrosis is promising. Compared with historic controls, open drainage of infected pancreatic necrosis represents a significant advance over more conventional surgical approaches. Controlled studies and more widespread experience are necessary for further evaluation of this procedure.

No abstract